15.6.1 Prevalence of exposure to secondhand smoke in the home
Secondhand smoke (SHS) causes or exacerbates a range of serious health conditions in children and non-smoking adults, including cardiovascular disease, respiratory disease, and cancer (see Chapter 4). Children are particularly vulnerable to the harms of secondhand smoke in their homes and cars, given their lack of autonomy and the long hours they spend in these environments. Disadvantaged groups, including Aboriginal and Torres Strait Islander peoples, are also more likely to be exposed to secondhand smoke at home (see Chapter 9). Conversely, smokers who keep their home smokefree are more likely to be younger, male, and more highly educated. Smokefree homes are also associated with the presence of non-smokers, particularly children, lower cigarette consumption (or addiction) level, and interest in quitting. 1
In Australia, only a small minority of households with children and non-smokers allow smoking inside the home—see Section 4.5 for a detailed overview of the prevalence of exposure to secondhand smoke in the home.
15.6.2 Factors affecting adoption of smokefree homes
Increasing prevalence of smokefree public places and workplaces has been associated in English-speaking countries with increasing numbers of smokefree homes. 1-4 Despite initial concerns regarding potential displacement of smoking into the home following smokefree legislation, legislative bans on smoking in public places appear to encourage people to establish voluntary home smoking restrictions through their influence on social norms. 3, 5-15 Public smoking bans may also lead to reductions in social inequalities in exposure to secondhand smoke among children. 16
220.127.116.11 Education campaigns
Education campaigns about smoking at home have become a regular part of tobacco control programs. Common themes include raising awareness of the health effects of secondhand smoke on children and encouraging parents to either quit or smoke outside. 17 In Australia, there is some evidence that these campaigns have been moderately helpful in increasing the number of people who make their homes smokefree. 18-20 Education campaigns involving the use of new media may present a low-cost platform for educating families about the importance of not smoking in the home. 21 However, there are likely to be complex social and cultural factors which may affect the extent to which families engage with information on this topic. 22, 23
At an individual level, while there have been some successful community and healthcare-based interventions, 24-27 evidence about the effectiveness of such programs is limited. 28 Interventions by healthcare professionals who provide routine child healthcare may be effective in preventing maternal smoking relapse, thereby reducing children’s exposure to secondhand smoke 28 A 2018 Cochrane review examining the effectiveness of interventions designed to reduce children’s exposure to secondhand smoke concluded that while a small number of interventions targeting parents and carers have been shown to reduce exposure and improve children's health, the features of effective interventions remain unclear, and the overall evidence base is very poor quality. The authors also found no clear evidence of differences in levels of success between different settings, including well‐child, ill‐child and community contexts, and limited support for the delivery of more intensive counselling interventions to parent(s). 29 Tobacco control efforts focused on reducing the prevalence of smoking across the entire population may do more to reduce children’s exposure to secondhand smoke than efforts aimed directly at individual parents. 1
Some research has suggested that the provision of personalised feedback about secondhand smoke exposure in the home (such as measuring the level of indoor particulate matter in the home, and providing these measurements to parents together with information regarding health-based exposure guidelines) may assist in motivating parents to stop smoking in the home. 30, 31 A randomised trial in the US found that real-time feedback for air particle levels and brief coaching reduced fine particle levels in homes with smokers and young children. 32 However, even after the successful implementation of interventions that reduce tobacco smoke pollution in homes, contamination remains. Multifaceted individual and population-level strategies are likely necessary to effectively eliminate exposure.
15.6.3 Benefits of smokefree homes
Along with reducing children’s and non-smokers’ exposure to the harmful health effects of secondhand smoke, in its comprehensive evidence review published in 2009, the International Agency for Research on Cancer (IARC) concluded that smokefree homes can also have positive effects on smoking behaviours. Such restrictions lead to reduced adult smoking—both through reduced consumption and through supporting quit attempts. Smokefree homes may also reduce tobacco use among young people, with evidence showing that fewer teenagers of non-smoking parents who live in smokefree homes initiate smoking compared to children from a home that is not smoke-free. 1
15.6.4 Multi-unit dwellings
‘Neighbour smoke’ is a relatively new concept in tobacco control. 33 Several published studies now have documented significant transfer of secondhand smoke between dwellings in multi-unit apartment complexes. 34, 35 Research conducted in Australia and overseas suggests that people living in multi-unit housing are more likely to be exposed to secondhand smoke than those living in separate housing. 36-39 Children in apartments have been found to have higher average cotinine levels (an indicator of tobacco smoke exposure) than children in detached houses. 37 A Korean study of multi-unit housing found that more than half of the homes without smokers had secondhand smoke infiltration, which was associated with wheeze, rhinitis, and eczema symptoms in children. 40 No safe level of exposure to secondhand smoke has been identified. 41
Air sealing and modifications to ventilation can reduce, but not completely eliminate, smoke drift from apartments where residents smoke indoors. 42 Studies measuring air-nicotine concentrations and particulate matter have shown that air pollution increases in homes and common areas located adjacent to areas where smoking occurs. 34, 43, 44 This is because smoke can easily spread via gaps in door and window jambs, mechanical ventilation and air conditioning systems, elevator shafts, hallways, stairwells, cracks in walls, balconies and courtyards. 44
18.104.22.168 Australian regulations on smoking in multi-unit housing
Interest in protecting residents from secondhand smoking in multi-unit developments is growing in Australia. In 2009 the National Preventative Health Taskforce recommended state and territory governments take action to “protect residents from exposure to smoke-drift in multi-unit developments”. 45 The National Tobacco Strategy (2012–2018) includes an action item to “Monitor the issue of smoking and smoke-drift at residential premises and consider policy approaches to support smoke-free homes, particularly where children are present”. It states that responsibility lies with state and territory governments, as well as non-government organisations. 46
While smoking is banned in enclosed common or shared areas of multi-unit housing in several Australian states and territories, private living areas are generally exempt from these bans. However, it may be possible for owners corporations to agree to adopt their own by-laws or rules banning smoking in both common areas and private living areas. In 2011 the owners of a block of apartments in Ashfield, Sydney agreed to a by-law banning smoking anywhere within the building and on balconies, making the building the first multi-unit dwelling in Australia to become 100% smokefree. Furthermore, in the case of Solerno v Proprietors of Strata Plan No 42724, the Supreme Court of New South Wales confirmed the validity of a by-law adopted by an owners corporation which banned smoking on common property and within any private living area.
Where an owners corporation does not adopt its own set of rules or by-laws, the ‘model rules’ or ‘model by-laws’ set out in the relevant state/territory regulations will apply. In most jurisdictions, the model rules or by-laws include a general provision prohibiting residents or visitors from causing a ‘nuisance’ or ‘hazard’ to other residents. Although such provisions do not specifically refer to smoking, it may be possible for residents to rely upon these general provisions to prevent others from smoking on common property or even in private living spaces. A review of strata laws in Australia recommends that State and Territory governments reform their strata laws to provide legislative recognition that secondhand may be considered to be a nuisance or a hazard and include a model by-law on smoking and give owners corporations explicit powers to make by-laws that regulate or completely ban smoking. It notes that the principles of nuisance and hazard have been applied inconsistently between jurisdictions. 47
For example, in 2006 the New South Wales Consumer, Trader and Tenancy Tribunal upheld a case brought by occupants of an apartment against their smoking neighbours, requiring them to stop smoking in their adjacent apartment because of smoke drift. 48 The occupants relied on a general by-law which prohibited residents from causing a nuisance to other occupants. This case could precipitate other such actions and give license to rental managers to advise tenants that smoking is banned in rental apartments. However, a number of similar cases brought before Tribunals in Queensland have been dismissed.
New South Wales is currently the only Australian jurisdiction with model by-laws which specifically address the issue of smoking in multi-unit housing. The model by-laws are contained in the Strata Schemes Management Regulation 2016 (NSW), and include a ‘tier’ of by-laws regarding smoking from which an owners corporation can choose. Where an owners corporation has not made a selection between the tiers, the ‘default’ tier will apply. The ‘default’ by-law prohibits smoking on common property, but not in private living areas. However, under the default by-law an owner or occupier has an obligation to ensure that smoke from a private living areas does not penetrate common property or any other private space.
The Queensland Government is undertaking a review of Queensland’s property laws, and is considering (among other matters) the issue of smoke infiltration. The regulation of smoking in private lots and on common property was one of the issues raised during stakeholder meetings. 49 The consultation sought feedback on a proposal to empower owners corporations to prohibit smoking on balconies, or where a structure is within four metres of another structure on an adjacent lot, as well as any other ideas regarding how smoking could be dealt with by owners corporations. The Options Paper for the review noted: “The law has increasingly recognised a need to protect non-smokers from the harmful effects of second hand smoke in public areas and workplaces. There is little reason not to extend this protection to people in a community title scheme. Residential bodies corporate are one of the only places of concentrated occupation to which no power is given to restrict (or prohibit) smoking except on common property.” 49 The final report released in 2017 recommended: “A by-law prohibiting smoking in an outdoor area that is part of a lot (including balconies, courtyards, etc) or on common property (including common property subject to an exclusive use by-law) should be enforceable against lot owners and occupiers if: the original owner includes the by-law in the schedule of by-laws attached to the first community management statement (CMS) for the scheme; or the body corporate adopts the by-law by a resolution without dissent. Aside from this different threshold required to adopt the by-law, a no smoking by-law will be added to the CMS and enforceable in the same way as any other by-law for the scheme. Amending or removing a no smoking by-law will also require a resolution without dissent. For the removal of doubt, the adoption of this recommendation will require a change to the power of the body corporate to regulate activity so that prohibition on smoking in an outdoor area that is part of a lot or on common property where that smoke drifts to an adjacent lot is permissible and not unreasonable or oppressive.” 50
The Australian Capital Territory recognises smoke-drift in multi-unit developments as part of its work on restricting places of tobacco use under its plan ‘ Future directions for tobacco reduction in the ACT 2013–2016’. 51 In 2018, the ACT Government released a fact sheet on managing smoke drift in multi-unit developments. It recommends using existing by-laws in the Unit Titles (Management) Act 2011 to address smoke drift that prohibit hazards or nuisances, or the mechanism whereby an owners corporation can move to amend rules. 52
In Victoria, the issue of smoke infiltration in multi-unit housing is being considered as part of a review undertaken by Consumer Affairs Victoria regarding the state’s consumer property laws. In an Options Paper released in November 2016, Consumer Affairs Victoria sought feedback regarding a proposal to amend Victoria’s existing model rules to include a specific rule addressing smoking in multi-unit housing (among other things). 53, 54 The proposed amendment to the Owners Corporations Act 2006 was released for public consultation in 2019, and allows for owners corporations to make rules “Regulating or prohibiting the drifting of tobacco smoke from a lot in a multi-level development”. 55 Quit Victoria, while broadly supporting the amendment, recommended that it be broadened to ensure that owners corporations in both single and multi-level developments have the power to make rules addressing smoking; that owners corporations be given the power to specifically regulate or prohibit smoking (rather than the ‘drifting of smoke’); that owners corporations be given a clear power to prohibit or regulate smoking in both common areas and private lots (rather than private lots only); and that there be a choice of Model Rules available to owners corporations regarding the issue of smoking, with all choices prohibiting smoking in circumstances where smoke is able to infiltrate neighbouring private lots or common property. Subject to the resolution of any issues raised during the consultation process, the Bill should be introduced into Parliament later in 2019. 55
22.214.171.124 International trends in regulation of smoking in multi-unit housing
Internationally, there are growing calls for smoke-free multi-unit housing policies to protect the health of occupants. 56, 57 In particular, smoke-free laws and policies affecting multi-unit housing are becoming more prevalent in the US. Since 2009, the US Department of Housing and Urban Development has been strongly encouraging public housing authorities to adopt smoke-free policies. On 30 November 2016 the Department issued a final rule requiring Public Housing Authorities to adopt and implement a smokefree policy for all of their public housing properties by July 31, 2018. 58
Laws addressing smoking in multi-unit housing are also becoming more prevalent among US state and local governments. For example, state law in Utah recognises that tobacco smoke that drifts into a residential unit may be considered a ‘nuisance’. 59 Furthermore, a number of Californian local governments have enacted local laws prohibiting smoking in both private and common areas of multi-unit residences. Oregon and Maine mandate that rules (or absence of rules) about smoking must be disclosed to potential renters. 47
In Canada, while there are no federal laws that restrict smoking in private areas of multi-unit housing, laws in most Provinces and Territories prohibit smoking in common areas. Saskatchewan and the Yukon have implemented comprehensive smoking bans in publicly owned or leased properties. 60 Some municipal governments have also adopted smokefree policies in their public multi-unit housing and no law prohibits privately owned complexes from voluntarily adopting 100% smokefree policies. 47
126.96.36.199 Benefits of smoke-free policies in multi-unit housing
Research undertaken in the US indicates that smokefree policies in multi-unit housing reduce resident exposure to secondhand smoke, 61 decrease daily cigarette consumption amongst smoking residents, encourage smoking cessation and increase quit attempts. 62 Another US study found that while low-income smokers were significantly less likely to live
in smokefree homes, those who did live in such homes were much more likely to be successful quitters, suggesting that smokefree housing policies may be particularly beneficial for disadvantaged groups. 63
In addition, cost analyses indicate that there are considerable economic benefits associated with implementing smokefree policies in multi-unit residences, and that these benefits outweigh any implementation costs. 35, 64 Landlords have tended to over-estimate the negative commercial impact of proposed smoke-free policies. 65, 66 Following implementation, the actual impact of smoke-free policies on vacancy and turnover has been shown to be negligible, neutral or positive. 67, 68 A study of landlords who had implemented smokefree policies in apartment buildings in Douglas County Nebraska found that anticipated adverse consequences generally did not occur. 67 One US study estimated that prohibiting smoking in all US subsidised housing would result in cost savings of approximately $521 million per year. 69 The estimated savings were calculated based on reduced health care costs, reduced renovation costs, and reduced incidence or risk of smoking related fires. Several high-rise apartment building fires in Melbourne in recent years have been caused by cigarettes 70 (see also Section 3.19).
However, policy alone appears to be insufficient in reducing exposure and changing smoking behaviours. Several US studies have reported challenges with compliance since implementing smoking bans in multi-unit housing. 71-73 Residents of public housing in the US have suggested that improving access to cessation services, ongoing resident engagement, education and communication to address misconceptions and concerns about enforcement, and framing the policy as part of a broader wellness initiative could help increase compliance. 71, 74 The American Lung Association and Mental Health America announced in 2018 that they would be providing additional support for public housing residents living with behavioural health issues, such as mental illness and substance use disorders, to adjust to the new smokefree policy, remain in their homes and, for those interested in quitting, have access to cessation programs and services. 75
188.8.131.52 Public support for smoking bans in multi-unit housing
Although there is limited Australian research on support for smoking bans in multi-unit housing, only a small minority of Australians allow smoking in their home (see Section 4.5), suggesting that most people would support such measures. A 2017 survey found that 18 per cent of Victorians had been exposed to smoke drift at home in the previous week, and 85 per cent supported a ban on smoking in shared corridors, stairwells or laundries. 76 Cancer Councils across Australia report being contacted by many distressed residents of multi-unit housing, as well as landlords and representatives of owners corporations, looking for advice in how to eliminate secondhand smoke exposure. 47
International research has shown high levels of interest by owners, occupiers and managers in adopting smokefree policies. 77 A Canadian survey found that 46% of apartment dwellers had experienced smoke from a neighbour seeping into their apartment and 64% would prefer to live in an entirely smokefree complex. 78 In a survey published in 2010, the majority of apartment owners in New York expressed interest in introducing smokefree policies. 79 Prior to the implementation of smokefree public housing, most US adults expressed support for such a ban, although support was lower among smokers. 80 Although the US has banned smoking in public housing, the ban does not extend to private rentals that are subsidised for low-income residents. A survey of US adults found high levels of support for extending the bans to all indoor areas of multi-unit buildings that house such residents, even where some units were non-subsidised. 81 Another US study found multi-unit housing residents living with children strongly supported smokefree multi-unit housing. 82
184.108.40.206 Rationale for restricting smoking in cars
Australians spend a considerable amount of time in their cars. In Australia in 2012, approximately 7 in 10 (71%) adults travelled to work or full-time study primarily by car. The majority (88%) also used a car to get other places, such as to go shopping or visiting family and friends. 83 A 2018 survey found that almost two in three Australian children (64%) were being driven to school most days. 84 The family car has therefore traditionally been a source of significant secondhand smoke exposure among children. 85-87
The low air change rates of motor vehicles—designed to shelter occupants from air pollutants entering from outside a vehicle—also work to concentrate pollution from any sources inside the vehicle. Smoking just one or two cigarettes inside a car can substantially increase passengers’ exposure to tobacco smoke pollution, 88-90 even with the windows down. 86, 91, 92 This concentrated exposure can lead to serious health outcomes. A 2007 Australian study found that children exposed to tobacco smoke in the family vehicle were more likely to develop a persistent wheeze than those exposed in the home only. 93 Further, such exposure in cars is associated with an increased risk of smoking uptake in adolescence. 94 A study published in 2008 showed an increase in symptoms of nicotine dependence in children who had never smoked but who were exposed to tobacco smoke in cars. 95
Previously, private cars were regarded as the domain of the domestic environment, and therefore beyond the reach of regulation 96 Public acceptance of smokefree policies in the hospitality industry, concern about the health and rights of children as well as increasing regulation of the behaviour of motorists—including prohibition of the use of mobile phones—appear to have been some of the factors that have made the public and governments more amenable to the idea of prohibiting smoking in cars when children are present. 2, 97-102
In October 1995, a world-first study was published that measured support among adults in New South Wales for regulation of smoking in cars carrying children. 103 A substantial majority of respondents agreed that it should be illegal to smoke in cars when travelling with children (72%), 27% disagreed and 1% were undecided. The majority of smokers (63%), also agreed with a ban 104
In November 1995, a working party on the effects of passive smoking of the National Health Advisory Committee released a draft report, The Health Effects of Passive Smoking . The working party recommended that the ‘legal prohibition of smoking in private motor vehicles during periods when minors are passengers should be considered by State and Territory governments’ (p214). 105
Results from a large-scale population health survey in New South Wales reveal that by 2008, the vast majority of adults (88.2%) reported that smoking was not allowed in their car, a significant increase from 2003 (81.2%). A significantly lower proportion of people in the lowest socio-economic group (84.8%) and young adults aged 16–24 years (82.1%) reported smoking was not allowed in their car compared with the overall adult population.
220.127.116.11 Legislation banning smoking in cars in Australia
All Australian states and territories now have legislation in force which prohibits smoking in cars while children are present.
In June 2006, more than a decade after the issue of smoking in cars was first discussed in Australia, the Tasmanian Government released a discussion paper that included a proposal to ban smoking in cars carrying children in that state. 106 In March 2007 a proposal to introduce legislation banning smoking in cars carrying children under 18 was announced. 107 A Bill to amend s.67H(2) of the Public Health Act 1997 (Tas.) was passed and came into force on 19 December 2007, making Tasmania the first Australian jurisdiction to implement such a ban.
In February 2006, the South Australian Democrats proposed legislation to ban smoking in cars carrying children aged under 12 108 softening their previous position from a total smoking ban in cars. In August 2006 the South Australian Government announced plans to ban smoking in cars carrying children under the age of 16 with penalties of up to $200 applying. The Bill was passed in March 2007 and came into effect on 31 May 2007, World No Tobacco Day, making South Australia the first state in Australia to ban smoking in cars with children. The first reports of fines appeared in July 2007. 109
In November 2006, the Parliamentary Secretary to the Commonwealth Minister for Health and Ageing issued a media release urging the states and territories to enact legislation banning smoking in cars. 110 The possibility of national coordinated action for a ban was raised, but failed to be adopted at the December 2006 meeting of the Ministerial Council Drug Strategy.
In New South Wales smoking in cars when children are present was banned under the Public Health (Tobacco) Act 2008 (NSW) from July 2009.
In 2009 the Tobacco Products Control Amendment Act 2009 was introduced into Western Australia’s State Parliament by Dr Janet Woollard as a Private Member’s Bill. The new law was passed and smoking in cars when children under the age of 17 years are present was banned in Western Australia from 22 September 2009.
In 2009, the Australian Capital Territory Government expressed concern about the issue of smoking in cars, and released a discussion paper in 2009. 111 On 20 October 2011, the Smoking in Cars with Children (Prohibition) Act 2011 (ACT) was passed. The Act came into force on 1 May 2012, and prohibits smoking in cars when a person under the age of 16 is present.
Similar bans were introduced in both Queensland and Victoria on 1 January 2010. 112, 113
The Northern Territory was the last Australian jurisdiction to introduce a ban on smoking in cars when children are present. The relevant legislative provision came into operation on 1 December 2014, and applies where children under the age of 16 are present. 114
Table 15.6.1 provides a summary of legislation banning smoking on cars with children present in each Australian state/territory.
Summary of state/territory legislation concerning smoking in cars with minors
18.104.22.168 Restrictions on smoking in cars in countries outside Australia
Like Australia, all Canadian provinces and territories have implemented bans on smoking in cars with children. At least seven US states—Arkansas, California, Louisiana, Maine, Oregon, Utah and Vermont—have banned smoking in cars when children are present, along with the US territories of Puerto Rico and Guam. 115 The legislation in Guam also prohibits smoking in cars with pregnant women, 116 and many states ban smoking in cars when foster children are present. 115 France, Ireland, the UK, Mauritius, Bahrain, Cyprus, South Africa and the United Arab Emirates have also implemented bans on smoking in cars with children present.
Summary of legislation concerning smoking in cars with minors—as at 2017
Source: Global Advisors on Smokefree Policy 115 and Public Health Law Centre 116
^Note: Guam is US territory in the Western Pacific; Puerto Rico is US territory in the Caribbean
15.6.6 Home health and community care workers
Community nurses and other health and welfare workers may be repeatedly exposed to secondhand smoke while working with clients living in their own home or in community supported accommodation outside institutions. 117, 118 This is an occupational health and safety issue for these workers, and some institutions in the UK and Australia insist as a matter of policy that clients do not smoke in their presence. The Aged and Community Services Association of New South Wales and the Australian Capital Territory for instance advises agencies that all clients should be advised not to smoke in the presence of workers. 119
Relevant news and research
For recent news items and research on this topic, click here. (Last updated July 2019)
1. Australian Institute of Health and Welfare. 2013 National Drug Strategy Household Survey: Survey Report. Drug statistics series no. 28, AIHW cat. no. PHE 183.Canberra: AIHW, 2014. Available from: Available at: http://www.aihw.gov.au/publication-detail/?id=60129549469
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2. Borland R, Yong HH, Cummings KM, Hyland A, Anderson S, et al. Determinants and consequences of smoke-free homes: Findings from the international tobacco control (ITC) four country survey. Tobacco Control, 2006; 15(suppl. 3):iii42–50. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/suppl_3/iii42
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4. Moore GF, Moore L, Littlecott HJ, Ahmed N, Lewis S, et al. Prevalence of smoking restrictions and child exposure to secondhand smoke in cars and homes: A repeated cross-sectional survey of children aged 10-11 years in Wales. BMJ Open, 2015; 5(1):e006914. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25636793
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13. Wang Y-T, Tsai Y-W, Tsai T-I, and Chang P-Y. Children's exposure to secondhand smoke at home before and after smoke-free legislation in taiwan. Tobacco Control, 2017; 26(6):690–6. Available from: http://tobaccocontrol.bmj.com/content/tobaccocontrol/26/6/690.full.pdf
14. Lidon-Moyano C, Martinez-Sanchez JM, Fu M, Ballbe M, Martin-Sanchez JC, et al. Impact of the spanish smoking legislations in the adoption of smoke-free rules at home: A longitudinal study in barcelona (spain). Tobacco Control, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27625409
15. Ferketich AK, Lugo A, La Vecchia C, Fernandez E, Boffetta P, et al. Relation between national-level tobacco control policies and individual-level voluntary home smoking bans in Europe. Tobacco Control, 2016; 25(1):60–5. Available from: http://tobaccocontrol.bmj.com/content/25/1/60.abstract
16. Nanninga S, Lehne G, Ratz T, and Bolte G. Impact of public smoking bans on social inequalities in children’s exposure to tobacco smoke at home: An equity-focused systematic review. Nicotine & Tobacco Research, 2018:nty139–nty. Available from: http://dx.doi.org/10.1093/ntr/nty139
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28. Daly JB, Mackenzie LJ, Freund M, Wolfenden L, Roseby R, et al. Interventions by health care professionals who provide routine child health care to reduce tobacco smoke exposure in children: A review and meta-analysis. JAMA Pediatr, 2016; 170(2):138–47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26719991
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